Constraints to Change: Working with Adolescents – A Case Study

The following was prepared for a practitioner working with a late adolescent girl, Janette where change was not progressing as expected and if anything, the situation was going backwards. The supervisor reflects on the features of the case and the supervisory relationship as a way of mapping a path forward. 

 Constraint to Change  

In the matter of Janette, we are stuck, we are not able to produce any movement or change, in fact through our engagement with her, it does appear that she has gone backwards, and is more isolated now than she was in the beginning. Coronavirus has negatively impacted upon our therapeutic process with Janette. She has become more anxious about contact with other people and become more reclusive. Coronavirus is not something we could have reasonably predicted although, if we had known we could have reasonably predicted the impact this would have on Janette. So be it, this is where we are now. The harder we try, the more we work to change the situation, the more the situation with Janette stays the same. The more responsibility we take for change in this matter to less responsibility for change she appears to take. The more responsibility we take for Janette, the less responsibility her mother takes for changing Janette.
When a case is stuck, that means the naturally occurring change/ transformation process in the life of a human being such as Janette or in the life of a relationship system such as this family, is stalled, has stopped, has come to a grinding halt. It means that there are a set of constraints in this matter that either we cannot see, or we can see but cannot influence. Because of your particular genius in working with people who are challenged, you can ordinarily conjure influences out of nowhere, and you are able to do that often out of your seriously eccentric personality and intellect. This time that eccentricity is not working and is probably not going to work in the short term. What we have to do here is look at the therapeutic system, both of you as workers and myself as supervisor. We must ask ourselves what is happening in the therapeutic system that constrains this matter from changing in the direction and way we would naturally and ordinarily expect. We must ask ourselves whether there is something in the therapeutic relationship between us and Janette and the mother that constrains change; or is there something idiosyncratic in the family system that constrains change that we are not able to influence; or is there something in the relationship between the three of us as practitioners that constrains change. Constraint is the central systemic idea at the heart of working with matters for such as this. This is exactly the kind of case you need to teach you about the nature of constraint. Many constraints in the cases we handle can be tripped or tricked into change and transformation by simpler strategies that we use. That will not work in this case.
When something is as stuck as this matter, there should be several explanations, not a single explanation, for such stuckness. WE need to to look at the constraints to change existent in all four subsystems or sub parts of this matter. Those parts are:
1. The total system inclusive of the family; us as practitioners; Janette as an individual human being; the therapeutic system including us; Janette and her mother; and the world beyond us and this family
2. Janette
3. Us as practitioners
4. The specific therapeutic system
Each of these as socio-relational domain integral to the larger conceptualization of this matter may offer us one or more explanations relevant to this matter. Just remember, I am looking for several explanations, not one single explanation. We will know intuitively when we have enough explanations on the table. A multiplicity of explanations will reflect our more comprehensive understanding of constraint in this matter. What I see in this matter is that you work harder and harder and take more and more responsibility for the change process and Janette. So, we need to address constraint in each of the following domain –
1. The whole system.
2. Janette
3. The practitioner system
4. The family system
5.  The therapeutic system

We must ransack ourselves and our own souls in order to find the way forward for and with Janette. The change in Janette will be driven by a fundamental shift in us.

Key constraints in any family, personal, system or therapeutic arrangement are:
1. Socio-relational fractures in any of the systems involved especially with fractures between parties ordinarily attached with the other or in a close relationship
2. Responsibility and authority -  unequal, inappropriate or unbalanced apportionment of responsibility and authority
3. Isolation – being cut off from the socio-relational world – limits the influence of the socio-relational on the neuro-biological. Note; change ordinarily happens from the outside in
4. Neurobiological; mental health, anxiety etc. Neurobiological conditions that limit the ability of an individual person to effectively participate in their socio-relational world.
5. Drugs/Alcohol alter the spatial and temporal characteristics of an individual person, alter their internal neurobiology and their participation in the socio relational.
6. Developmental. The neurobiological is developmental, identity development is central which is defined in terms of productive identity, peer identity, attachment identity, and sexual identity.
7. Temporal. As humans we require a conceptualization of time future, time present and time past and we either do that for ourselves or we have it done for us. Nomadic and tribal societies do this collectively and it is certainly a much more reliable way of managing the temporal especially for those people who are unable to manage this for themselves. Humans who must do this for themselves experience varying levels of success in doing so. Time and identity development go together and are directly connected to the socio-relational, all of which requires the socio-relational to distribute responsibility and authority equitably and appropriately.

What is means is that there are fundamental constraints that apply to this matter being as follows:

1. Isolation and non-participation in the socio-relational world. Janette’s non-participation in the socio-relational world means that there is limited opportunity for identity development in the conventional sense and she cannot develop a peer group, a group of people like herself, she cannot develop a productive identity, which would connect her to a group of people similar to herself, she cannot differentiate from her own attachment world which means the opportunities for growing up are very limited. Whilst she remains as isolated as this there is very little opportunity for change, and you have very little therapeutic leverage to produce change. You are left to convince, a difficult to convince, neurobiological inside structure. That is essentially what you are working on with her.
2. Responsibility and authority. Essentially all the responsibility in this matter has been handed to you and you have accepted that responsibility. She and her mother retain all the authority in the matter,  hence the absence of therapeutic leverage.
3. Cooperation. You have an absence of cooperation from the mother that is disguised inside her passivity and inertia
4. Time.  Janette is a woman with no time future, living in a perpetual present tense, alone & isolated in which amplifies naturally occurring anxiety and creates mental health issues out ordinary life fluctuations 
5. Fracture.  Are there any fractures in the therapeutic system we need to consider? In my view we are certainly nor on the same page
6. Space. She is preoccupied with the inside neurobiological which will paralyze her socio-relationally

Change

We need to be clear that Janette will not change whilst she remains in isolation. 
Her anxiety will not alter in isolation and in fact it will probably get worse living in isolation in a perpetual present tense with no futur.e
Her identity will not develop in isolation and her development will remain paralyzed and be compromised. You need to specifically unpack exactly what this means in terms of sexuality and sexual development, in terms of peer relationships of similarity, and in particular the fact that she will not grow up, which requires differentiation from her family. That cannot occur in isolation, it can only occur in a socio-relational world beyond her family. Human development is socio-relational, the socio-relational makes manifest neurobiological potential and possibility.
Whilst all the responsibility for change is in your hands and all the authority for obstructing change is in her hands (and coincidentally in the hands of her mother) you have no chance of achieving any change
You were asked to produce change and you cannot produce change under these circumstances.
The entire basis for service delivery in this matter is flawed and needs to be completely reviewed and revised so that you have the authority to do what you have been asked to take responsibility for doing.  The request in this matter and the contract for service delivery must bring responsibility and authority into alignment, and the failure to achieve that will paralyze the therapeutic process and persuade you into trying to change her from the inside out, to change her neurobiologically, which you will not achieve That will require medication.
The fact that Janette is unable to make a request of you is very significant.  if she is unable to make a request of you, then we need to know who can make a request of us in relationship to her symptoms. Obviously that person is the mother. So, the dialogue we have with the mother becomes extremely significant as an opportunity for us to get an appropriately formulated request that allows us to put responsibility and authority back into alignment. Janette is her adult daughter; she is not a child so the politics and the legalities of putting that request together are complex. In my view we need to enter that complexity to pick our way forward in this matter and to deal with the impotence you as a practitioner.  My task as the Director of the Complex Needs Clinic is to address your therapeutic impotence in relationship to Janette. 
My observation about this case. Such impotence is not something you sit comfortably with, something you rail against. Such impotence will persuade you to work therapeutically harder and harder. You are accustomed to being extremely potent which is your particular genius doing a genius job. My particular skill is getting your genius to do its job, letting it do its job, not getting in the way. In other matters that strategy on my part was successful, in this case this has not been a successful strategy so I need to adopt an entirely different strategy with you and this case. My failure to intervene earlier has probably left you more vulnerable to your own intolerance of your own impotence. 

Action

Meet with both mother and daughter to negotiate a new request/contract that brings responsibility and authority into alignment. Finding such a new request is going to be extremely difficult.
Getting the cooperation of all relevant parties to deliver on this request is going to be even more difficult. Limited cooperation will constrain our ability to deliver on this new request.